Chapter DWD 81

DWD 81.07(6)(d) (d) The surgical therapies in subds. 1. and 2. have very limited application and require a personality or psychosocial evaluation that indicates the patient is likely to benefit from the treatment.

DWD 81.07(6)(d)1. 1. Spinal cord stimulator may be necessary for a patient who has neuropathic pain and has had a favorable response to a trial screening period.

DWD 81.07(6)(d)2. 2. Intrathecal drug delivery system may be necessary for a patient who has somatic or neuropathic pain and has had a favorable response to a trial screening period.

DWD 81.07(7) (7) Chronic management. Chronic management of neck pain shall be provided according to the guidelines in s. DWD 81.13.

DWD 81.07(8) (8) Durable medical equipment.

DWD 81.07(8)(a) (a) A health care provider may direct the use of durable medical equipment only as specified in pars. (b) to (e).

DWD 81.07(8)(b) (b) Cervical collars, braces or supports, and home cervical traction devices may be necessary within the guidelines of sub. (3) (f) and (k).

DWD 81.07(8)(c) (c) For patients using electrical muscle stimulation at home, the device and any required supplies are necessary within the guidelines of sub. (3) (e).

DWD 81.07(8)(d) (d) Exercise equipment for home use, including bicycles, treadmills, and stairclimbers are necessary only as part of an approved chronic management program. This equipment is not necessary during initial nonoperative care or during reevaluation and surgical therapy. If the employer has an appropriate exercise facility on its premises with the prescribed equipment, the insurer may mandate the use of that facility instead of authorizing purchase of equipment for home use.

DWD 81.07(8)(d)1. 1. ‘Indications.’ The patient is deconditioned and requires reconditioning that may be accomplished only with the use of the prescribed exercise equipment. A health care provider shall document specific reasons why the exercise equipment is necessary and may not be replaced with other activities.

DWD 81.07(8)(d)2. 2. ‘Requirements.’ The use of the equipment shall have specific goals and there shall be a specific set of prescribed activities.

DWD 81.07(8)(e) (e) All of the following durable medical equipment is not necessary for home use for neck pain conditions:

DWD 81.07(8)(e)1. 1. Whirlpools, Jacuzzis, hot tubs, and special bath or shower attachments.

DWD 81.07(8)(e)2. 2. Beds, waterbeds, mattresses, chairs, recliners, and loungers.

DWD 81.07(9) (9) Evaluation of treatment by health care provider.

DWD 81.07(9)(a) (a) A health care provider shall evaluate at each visit whether the treatment is medically necessary and whether initial nonsurgical management is effective according to pars. (b) to (e). No later than the time for treatment response established for the specific modality in subs. (3) to (5), a health care provider shall evaluate whether the passive, active, injection, or medication treatment modality has resulted in progressive improvement as specified in pars. (b) to (e).

DWD 81.07(9)(b) (b) The patient’s subjective complaints of pain or disability are progressively improving, as evidenced by documentation in the medical record of decreased distribution, frequency, or intensity of symptoms.

DWD 81.07(9)(c) (c) The objective clinical findings are progressively improving, as evidenced by documentation in the medical record of resolution or objectively measured improvement in physical signs of injury.

DWD 81.07(9)(d) (d) The patient’s functional status, especially vocational activity, is progressively improving, as evidenced by documentation in the medical record or documentation of work ability involving less restrictive limitations on activity.

DWD 81.07(9)(e) (e) If there is not progressive improvement in at least 2 categories specified in pars. (b) to (d), the modality shall be discontinued or significantly modified or a health care provider shall reconsider the diagnosis. The evaluation of the effectiveness of the treatment modality may be delegated to another health care provider.

DWD 81.07(10) (10) Medication management.

DWD 81.07(10)(a) (a) Prescription of controlled substance medications scheduled under ch. 450, Stats., including opioids and narcotics, are indicated primarily for the treatment of severe acute pain. These medications are not recommended in the treatment of patients with persistent regional neck pain.

DWD 81.07(10)(b) (b) Patients with radicular pain may require longer periods of treatment.

DWD 81.07(10)(c) (c) A health care provider shall document the rationale for the use of any scheduled medication. Treatment with nonnarcotic medication may be appropriate during any phase of treatment and intermittently after all other treatment has been discontinued. The prescribing health care provider shall determine that ongoing medication is effective treatment for the patient’s condition.

DWD 81.07(11) (11) Specific treatment guidelines for regional neck pain.

DWD 81.07(11)(a) (a) A health care provider shall use initial nonsurgical treatment for the first phase of treatment for all patients with regional neck pain under sub. (1) (b) 1.

DWD 81.07(11)(a)1. 1. The active, passive, injection, durable medical equipment, and medication treatment modalities and procedures in subs. (3), (4), (5), (8), and (10), may be used in sequence or simultaneously during the period of initial nonsurgical management depending on the severity of the condition.

DWD 81.07(11)(a)2. 2. The only therapeutic injections necessary for patients with regional neck pain are trigger point injections, facet joint injections, facet nerve blocks, and epidural blocks, and their use must meet the guidelines of sub. (5).

DWD 81.07(11)(a)3. 3. After the first week of treatment, initial nonsurgical treatment shall at all times contain active treatment modalities according to the guidelines of sub. (4).

DWD 81.07(11)(a)4. 4. Initial nonsurgical treatment shall be provided in the least intensive setting consistent with quality health care practices.

DWD 81.07(11)(a)5. 5. Except as otherwise provided in sub. (3), passive treatment modalities in a clinic setting or requiring attendance by a health care provider are not necessary beyond 12 weeks after any passive modality other than bedrest or bracing is first initiated.

DWD 81.07(11)(b) (b) Surgical evaluation or chronic management is necessary if the patient continues with symptoms and physical findings after the course of initial nonsurgical management and if the patient’s condition prevents the resumption of the regular activities of daily life, including regular vocational activities. The purpose of surgical evaluation is to determine whether surgery is necessary in the treatment of a patient who has failed to recover with initial nonsurgical care. If the patient is not a surgical candidate, then chronic management is necessary.

DWD 81.07(11)(b)1. 1. Surgical evaluation if necessary may begin as soon as 8 weeks after, but shall begin no later than 12 weeks after, beginning initial nonsurgical management. An initial recommendation or decision against surgery does not preclude surgery at a later date.

DWD 81.07(11)(b)2. 2. Surgical evaluation may include the use of appropriate medical imaging techniques. The imaging technique shall be chosen on the basis of the suspected etiology of the patient’s condition but a health care provider shall follow the guidelines of s. DWD 81.05. Medical imaging studies that do not meet these guidelines are not necessary.

DWD 81.07(11)(b)3. 3. Surgical evaluation may also include diagnostic blocks and injections. These blocks and injections are only necessary if their use is consistent with the guidelines of sub. (1) (j).

DWD 81.07(11)(b)4. 4. Surgical evaluation may also include personality or psychosocial evaluation, consistent with the guidelines of sub. (1) (i).

DWD 81.07(11)(b)5. 5. Consultation with other health care providers may be appropriate as part of the surgical evaluation. The need for consultation and the choice of consultant will be determined by the findings on medical imaging, diagnostic analgesic blocks, and injections, if performed, and the patient’s ongoing subjective complaints and physical findings.

DWD 81.07(11)(b)6. 6. The only surgical procedure necessary for patients with regional neck pain only is cervical arthrodesis, with or without instrumentation, which shall meet the guidelines in sub. (6). For patients with failed surgery, spinal cord stimulators or intrathecal drug delivery systems may be necessary consistent with the guidelines of sub. (6) (d).

DWD 81.07(11)(b)6.a. a. If surgery is necessary, it shall be offered to the patient as soon as possible. If the patient agrees to the proposed surgery, it shall be performed as expeditiously as possible, consistent with sound medical practice.

DWD 81.07(11)(b)6.b. b. If surgery is not necessary or if the patient does not wish to proceed with surgical therapy, then the patient is a candidate for chronic management.

DWD 81.07(11)(c) (c) If the patient continues with symptoms and objective physical findings after surgery has been rendered or the patient refuses surgery or the patient was not a candidate for surgery, and if the patient’s condition prevents the resumption of the regular activities of daily life including regular vocational activities, then the patient may be a candidate for chronic management under s. DWD 81.13.

DWD 81.07(12) (12) Specific treatment guidelines for radicular pain, with or without regional neck pain, with no or static neurologic deficits.

DWD 81.07(12)(a) (a) Initial nonsurgical treatment is appropriate for all patients with radicular pain, with or without regional neck pain, with no or static neurologic deficits under sub. (1) (b) 2., and shall be the first phase of treatment. It shall be provided within the guidelines of sub. (11) (a), with the following modifications: Epidural blocks, nerve root, and peripheral nerve blocks are the only therapeutic injections necessary for patients with radicular pain only. If there is a component of regional neck pain, therapeutic facet joint injections, facet nerve blocks, and trigger point injections may also be necessary.

DWD 81.07(12)(b) (b) Surgical evaluation or chronic management is necessary if the patient continues with symptoms and physical findings after the course of initial nonsurgical care and if the patient’s condition prevents the resumption of the regular activities of daily life, including regular vocational activities. It shall be provided within the guidelines of sub. (11) (b), with the following modifications: The only surgical procedures necessary for patients with radicular pain are decompression of a cervical nerve root which shall meet the guidelines of sub. (6) and s. DWD 81.12 (1) (c) and cervical arthrodesis, with or without instrumentation. For patients with failed surgery, spinal cord stimulators or intrathecal drug delivery systems may be necessary consistent with sub. (6) (d).

DWD 81.07(12)(c) (c) If the patient continues with symptoms and objective physical findings after surgical therapy has been rendered or the patient refused surgical therapy or the patient was not a candidate for surgical therapy, and if the patient’s condition prevents the resumption of the regular activities of daily life including regular vocational activities, then the patient may be a candidate for chronic management. Any course or program of chronic management for patients with radicular pain, with or without regional neck pain, with static neurologic changes shall be provided under the guidelines of s. DWD 81.13.

DWD 81.07(13) (13) Specific treatment guidelines for radicular pain, with or without regional neck pain, with progressive neurologic deficits.

DWD 81.07(13)(a) (a) Patients with radicular pain, with or without regional neck pain, with progressive neurologic deficits may require immediate or emergency evaluation at any time during the course of their overall treatment. A health care provider may make the decision to proceed with surgical evaluation based on the type of neurologic changes observed, the severity of the changes, the rate of progression of the changes, and the response to any nonsurgical treatments. Surgery, if necessary, may be performed at any time during the course of treatment. Surgical evaluation and surgery shall be provided within the guidelines of sub. (11) (b), with the following modifications:

DWD 81.07(13)(a)1. 1. Surgical evaluation and surgical therapy may begin at any time.

DWD 81.07(13)(a)2. 2. The only surgical procedures necessary for patients with radicular pain are decompression of a cervical nerve root that shall meet the guidelines of sub. (6) and s. DWD 81.12 (1) (c), or cervical arthrodesis, with or without instrumentation. For patients with failed back surgery, spinal cord stimulators or intrathecal drug delivery systems may be necessary consistent with the guidelines of sub. (6) (d).

DWD 81.07(13)(b) (b) If a health care provider decides to proceed with a course of nonsurgical care for a patient with radicular pain with progressive neurologic changes, it shall follow the guidelines of sub. (12) (a).

DWD 81.07(13)(c) (c) If the patient continues with symptoms and objective physical findings after surgical therapy has been rendered or the patient refuses surgical therapy or the patient was not a candidate for surgical therapy, and if the patient’s condition prevents the resumption of the regular activities of daily life including regular vocational activities, then the patient may be a candidate for chronic management. Any course or program of chronic management for patients with radicular pain, with or without regional neck pain, with progressive neurologic changes at first presentation shall be provided under the guidelines of s. DWD 81.13.

DWD 81.07(14) (14) Specific treatment guidelines for myelopathy.

DWD 81.07(14)(a) (a) Patients with myelopathy may require emergency surgical evaluation at any time during the course of their overall treatment. A health care provider may make the decision to proceed with surgical evaluation based on the type of neurologic changes observed, the severity of the changes, the rate of progression of the changes, and the response to any nonsurgical treatments. Surgery, if necessary, may be performed at any time during the course of treatment. Surgical evaluation and surgery shall be provided within the guidelines of sub. (6) (b), with the following modifications:

DWD 81.07(14)(a)1. 1. Surgical evaluation and surgical therapy may begin at any time.

DWD 81.07(14)(a)2. 2. The only surgical procedures necessary for patients with myelopathy are anterior or posterior decompression of the spinal cord, or cervical arthrodesis with or without instrumentation. For patients with failed back surgery, spinal cord stimulators or intrathecal drug delivery systems may be necessary consistent with the guidelines of sub. (6) (d).

DWD 81.07(14)(b) (b) If a health care provider decides to proceed with a course of nonsurgical care for a patient with myelopathy, it shall follow the guidelines of sub. (12) (a).

DWD 81.07(14)(c) (c) If the patient continues with symptoms and objective physical findings after surgical therapy has been rendered or the patient refuses surgical therapy or the patient was not a candidate for surgical therapy, and if the patient’s condition prevents the resumption of the regular activities of daily life including regular vocational activities, then the patient may be a candidate for chronic management. Any course or program of chronic management for patients with myelopathy shall be provided under the guidelines of s. DWD 81.13.

DWD 81.07 History History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07.

DWD 81.08 DWD 81.08 Thoracic back pain.

DWD 81.08(1) (1) Diagnostic procedures for treatment of thoracic back injury.

DWD 81.08(1)(a) (a) A health care provider shall determine the nature of the thoracic back condition before initiating treatment.

DWD 81.08(1)(b) (b) A health care provider shall perform and document an appropriate history and physical examination. Based on the history and physical examination, a health care provider shall assign the patient at each visit to the appropriate clinical category in subds. 1. to 3. A health care provider shall document the diagnosis in the medical record. For the purposes of subds. 2. and 3., “radicular pain” means pain radiating in a dermatomal distribution around the chest or abdomen. This section does not apply to fractures of the thoracic spine or thoracic back pain due to an infectious, immunologic, metabolic, endocrine, neurologic, visceral, or neoplastic disease process.

DWD 81.08(1)(b)1. 1. Regional thoracic back pain includes the diagnoses of thoracic strain, sprain, myofascial syndrome, musculoligamentous injury, soft tissue injury, and any other diagnosis for pain believed to originate in the discs, ligaments, muscles, or other soft tissues of the thoracic spine and that affects the thoracic region, including ICD-9-CM codes 720 to 720.9, 721 to 721.0, 721.5 to 721.90, 722.3 to 722.30, 722.4, 722.6, 722.9 to 722.91, 723 to 723.3, 723.5 to 723.9, 724.5, 724.8, 724.9, 732.0, 737 to 737.9, 738.4, 738.5, 739.1, 756.1 to 756.19, 847 to 847.0, 920, 922.3, 925, and 926.1 to 926.12.

DWD 81.08(1)(b)2. 2. Radicular pain, with or without regional thoracic back pain, includes the diagnoses of thoracic radiculopathy, radiculitis, or neuritis; displacement or herniation of intervertebral disc with radiculopathy, radiculitis, or neuritis; spinal stenosis with radiculopathy, radiculitis, or neuritis; and any other diagnoses for pain believed to originate with irritation of a nerve root in the thoracic spine, including ICD-9-CM codes 721.1, 721.91, 722 to 722.0, 722.2, 722.7 to 722.71, 723.4, and 724 to 724.00.

DWD 81.08(1)(b)3. 3. Thoracic compressive myelopathy, with or without radicular pain, is a condition characterized by weakness and spasticity in one or both legs and associated with any of the following: exaggerated reflexes, an extensor plantar response, bowel or bladder dysfunction, sensory ataxia, or bilateral sensory changes.

DWD 81.08(1)(c) (c) A health care provider may not order laboratory tests in the evaluation of a patient with regional thoracic back pain, or radicular pain, except for any of the following:

DWD 81.08(1)(c)1. 1. When a patient’s history, age, or examination suggests infection, metabolic-endocrinologic disorders, tumorous conditions, systemic musculoskeletal disorders, such as rheumatoid arthritis or ankylosing spondylitis.

DWD 81.08(1)(c)2. 2. To evaluate potential adverse side effects of medications.

DWD 81.08(1)(c)3. 3. As part of a preoperative evaluation.

DWD 81.08(1)(d) (d) Laboratory tests may be ordered at any time a health care provider suspects any of the conditions specified in par. (c), but a health care provider shall justify the need for the tests ordered with clear documentation of the indications.

DWD 81.08(1)(e) (e) Medical imaging evaluation of the thoracic spine shall be based on the findings of the history and physical examination and may not be ordered prior to a health care provider’s clinical evaluation of the patient. Medical imaging may not be performed as a routine procedure and shall comply with the guidelines in s. DWD 81.05. A health care provider shall document the appropriate indications for any medical imaging studies obtained.

DWD 81.08(1)(f) (f) A health care provider may not order electromyography and nerve conduction studies for regional thoracic back pain and radicular pain under par. (b) 1. to 3.

DWD 81.08(1)(g) (g) A health care provider may not order the use of any of the following procedures or tests for the diagnosis of any of the clinical categories in par. (b) 1. to 3.:

DWD 81.08(1)(g)1. 1. Surface electromyography or surface paraspinal electromyography.

DWD 81.08(1)(g)2. 2. Thermography.

DWD 81.08(1)(g)3. 3. Plethysmography.

DWD 81.08(1)(g)4. 4. Electronic X-ray analysis of plain radiographs.

DWD 81.08(1)(g)5. 5. Diagnostic ultrasound of the spine.

DWD 81.08(1)(g)6. 6. Somatosensory evoked potentials and motor evoked potentials.

DWD 81.08(1)(h) (h) A health care provider may not order computerized range of motion or strength measuring tests during the period of initial nonsurgical care, but may order these tests during a period of chronic management when used in conjunction with a computerized exercise program, work hardening program, or work conditioning program. During the period of initial nonoperative care computerized range of motion or strength testing may be performed but shall be done in conjunction with an office visit with a health care provider’s evaluation or treatment, or physical or occupational therapy evaluation or treatment.

DWD 81.08(1)(i) (i) A health care provider may order personality or psychological evaluations for evaluating patients who continue to have problems despite appropriate care. A treating health care provider may perform this evaluation or may refer the patient for consultation with another health care provider in order to obtain a psychological evaluation. These evaluations may be used to assess the patient for a number of psychological conditions that may interfere with recovery from the injury. Since more than one of these psychological conditions may be present in a given case, a health care provider performing the evaluation shall consider all of the following:

DWD 81.08(1)(i)1. 1. Is symptom magnification occurring?

DWD 81.08(1)(i)2. 2. Does the patient exhibit an emotional reaction to the injury, such as depression, fear, or anger, that is interfering with recovery?

DWD 81.08(1)(i)3. 3. Are there other personality factors or disorders that are interfering with recovery?

DWD 81.08(1)(i)4. 4. Is the patient chemically dependent?

DWD 81.08(1)(i)5. 5. Are there any interpersonal conflicts interfering with recovery?

DWD 81.08(1)(i)6. 6. Does the patient have a chronic pain syndrome or psychogenic pain?

DWD 81.08(1)(i)7. 7. In cases in which surgery is a possible treatment, are psychological factors likely to interfere with the potential benefit of the surgery?

DWD 81.08(1)(j) (j) All of the following are guidelines for diagnostic analgesic blocks or injection studies and include facet joint injection, facet nerve block, epidural differential spinal block, nerve block, and nerve root block: